Bottoming out implant after revision - is there something that can be done so it doesn’t happen again? (Photo)

Thank you for your question and photo. A photo with your arms at the side and not raised and side views would've been helpful. Based on this photo, you do have a well formed inframammary crease on both sides, although the left one is lower. You do not have bottoming out by strict definition. The inframammary incision which originally was in the breast crease, now traveled up to the lower pole of your breast. In my opinion, there are two reasons for this: 1. the anchor or Wise pattern incision is a poor design. The vertical limb is usually 4.5-5.0cm which is too short for the size of your implants. In your case it should be 8.5-9.5cm. If you measure the distance now from the nipple to the crease, I believe that would the case. 2. your implants are too large, and they have no place to go but stretch the skin inferiorly and laterally. I would recommend waiting a year before reevaluation. If they are truly bottomed out, then you might need a mesh reinforcement for the lower pole and IMF. Good luck.

Hi, thanks for your question. Following a face to face assessment the options are likely to include: using an alternative type of implant to reduce the risk of recurrence, change the plane of the implant (from below the muscle to above the muscle, assuming the implant is below the muscle), tighten up the skin at the bottom of the breast using a ‘melon slice’ technique, or to use an ‘internal bra’ to support the weight of the implant. This can take the form of using your own tissues, or reinforcing your own tissues with an absorbable mesh. A combination of techniques is likely to be required. I would recommend consulting a plastic surgeon with a specialist interest in aesthetic breast surgery.

Hello,Recurrent “bottoming out” is often a combination of implant characteristics and poor soft tissue support. Larger, smooth implants are more likely to lead to implant malposition. In addition to changing the implant, you may want to ask your surgeon about utilizing either an absorbable mesh or an ADM to provide additional support. Good luck.

I see you have what we call pseudoptosis on your left breast left greater than right.

This is probably my most common problem after breast lifts, and it usually occurs over years but can occur faster.

I will often suggest the use of mesh to help support the breast, and if the a patient is willing to go down in size that can be helpful.

Many times, revision with a graft (like galaflex or Durasorb) can prevent bottoming out. However, I’ve seen cases where the muscle is either released too much or naturally “window-shades” over time. This means that the muscle has pulled upwards and created a tight band above your implant, so every time you use your arm it pushes down on the implant. In this case, the only way to get the correct implant position is to convert to a pocket above the muscle, which has its own drawbacks. I recommend asking your original surgeon about the technique used during your revision. If a graft has already been used, it’s more likely that won’t work.

Hello and thank you for your question. Unfortunately bottoming out is a possibility when implants are used to add volume to the breast. One strategy to help decrease the potential of this happening is to utilize resorbable mesh such as TIGR or DuraSorb to help develop strong tissue/internal scar to help prevent this from happening. It acts like an internal brassiere to help suport the implant. The mesh eventually is integrated into your tissue and resorbs over a period is around 1-2 years.
I hope this helps answer your question. Wishing you the best of luck!

I would suggest using mesh to reinforce the weak area of your lower breasts and to go with smaller implants that will not place as much weight on this weak area. Do not go larger.

I have to say, I really dislike this term 'bottoming out' (BO) because it introduces a stigma to something that seems to happen quite commonly to breasts whether or not they have implants or other cosmetic surgery and this appearance is not necessarily unattractive in my view.

However, BO seems to be in the common dictionary of words that are used in a association with cosmetic surgery and patients like yourself believe that they have had deficient treatment of some kind or another when they are really undergoing a natural biological process of skin stretching, just in the same way that skin on your tummy stretches when there is a baby inside. It happens more to some people than others because some of us have more stretchy skin and collagen than others.

You probably ended up needing the uplift in the first place because your skin had tendency to be rather stretchy.

This term should be renamed Lower breast stretch or 'LoBS'

LoBS essentially means that the curve of the breast below the nipple elongates and stretches and this changes the balance and appearance of the breast.

As previously mentioned it can happen to patients who have never had surgery at all but they have stretchy skin and often heavier breasts and under these circumstances it is called 'pseudoptosis'.

If your skin decides that it wants to stretch then it's going to and even revision surgery may not be able to guaranteeably prevent this from happening - so it's up to you whether you decide you want to have repeated operations to try and compete with your own biology or accept things as they are - and based on your photos I do not think the appearance is perfectly attractive and feminine and not at all bad.

Surgical manoeuvres to try would be a melon slice mastopexy (i.e. removing a melon slice shaped piece of tissue from the lower breast) and doing so in such a way as to try and fix the position of the under breast fold with some strong stitches to the deeper stronger layers of tissue adjacent to the ribs. This could still cause you discomfort, however and could still end up with stretch.

If you had smaller implants there would be less weight on the skin underneath the breast so this would reduce your chance of LoBS

Some surgeons will use an internal biologic membrane or mesh to try and support the lower part of the breast / implant, possibly in combination with placing the implant under the muscle. This certainly adds complexity and cost to such a procedure.

Another option could be to abandon the implants altogether, allow breasts to settle and see if you get any recoil of lower breast and then as a second stage look to enlarge the size of the breasts with fat transfer (fat liposuction from another part of your body and transferred to the breasts). Probably would need to still do a melonslice as part of this depending on how much the skin recoils. This has advantage that more fat can be added to the upper part of the breast relative to lower part.

Oliver Harley Plastic Surgeon

To make an accurate assessment regarding the outcome of any plastic surgery procedure, we generally need to see a complete set of proper before and after pictures.
We don’t make assessments with the patient arms up in the air.
If you’ve had more than one procedure than ideally, we should have access to before and after pictures for each of your previous procedures.
Correcting implants that have bottomed out can be done and is usually done with closing the implant pocket permanent sutures with or without mesh or cadaver dermal products like Alloderm.
Correcting this complication is a bit tricky and it’s important that patient vet providers for their skill, incorrect bottomed out implants in order to make sure you’re with the right surgeon.
I suggest you schedule a few in person opinion consultations with other plastic surgeons in your community.
For second opinion, consultations, come prepared bringing with you a complete set of before and after pictures for each of your previous procedures and copies of your previous operative reports.
The are part of your medical record and you can request from your current provider.
in person consultation ask provider to open up their portfolio and show you their entire collection of before and after pictures of previous patients who’ve had bottomed out implants corrected.
Ideally, your pectoralis muscle should be holding the implants in place.
This usually also requires that the surgeon maintained the integrity of the IMF (infra mammary fold) to a sufficient level to support the weight of the implants. If too much of the pectoralis muscle is transacted or if the implants are put above the muscle, then the implants are not held in place by the correct tissues.
It’s important to find the right surgeon to do this kind of work.
Having a repeat operations will increase complexity and overall decrease the chance of a quality long-term outcome.
Consider looking for plastic surgeons who do a lot of breast cancer reconstruction in your area if you’re having a difficulty finding those who have sufficient skill and experience.
Plan on having multiple consultations before selecting a provider.
Best,
Mats Hagstrom MD